A detailed description of Management of female infertility. References are taken from High standard infertility textbooks.

2. EVALUVATION
&
MANAGEMENT
OF
FEMALE
INFERTILITY
S. Rasik Fareed
Vth Unit, KGH

3. OUR ROLE
GIVE HER MENTAL SUPPORT
FIND THE CAUSE OF HER PROBLEM
FIND A WAY TO CORRECT IT
EDUCATE HER ABOUT THERAPY
DISCUSS ALTERNATIVES

5. • In old days, WOMEN WERE BLAMED when
couples did not have children
• Disorders in Men in 20-30 PERCENT OF CASES,
disorders in women in 40-55 PERCENT OF CASES,
and disorders of both in 10-40 percent.
• Severe psychological stress
• Self-blame
• Marital disharmony or emotional conflicts
• Complicated with hormone therapy
• Cost

7. CAUSES OF FEMALE INFERTILITY
Ovulatory factor
Tubal factor
Uterine factor
Cervical factor
Pelvic factor
Unexplained

8. INDICATIONS FOR EVALUATION
• Evaluation should be offered to all couples who have FAILED TO CONCEIVE
AFTER A YEAR OR MORE OF REGULAR UNPROTECTED
INTERCOURSE, but a year of infertility is not a prerequisite for evaluation.
• Earlier evaluation is justified for:
➢ Women with irregular or infrequent menses
➢ H/O pelvic infection or endometriosis
➢ Male partner with known or suspected poor semen quality
• 6 MONTHS OF UNSUCCESSFUL EFFORT IN WOMEN > 35 YEARS

9. INITIAL ASSESSMENT
• BOTH PARTNERS SHOULD BE PRESENT
• Complete medical, surgical and gynecological history of the women should be
obtained.
• Risk factors to be evaluated.
• Physical examination of the women.
• Basic investigations mandatory before start of treatment.

10. • Hormones to regularize cycles, drugs for ovulation induction
• Symptoms of PID, STI
• Genital TB
• Hyper/hypo Thyroid, DM
• PCOD
• Previous abdominal or pelvic surgery
• Previous pregnancy, abortion
GENERAL HISTORY

11. MENSTRUAL HISTORY
• Cycles
• Pain
• Flow

12. OVULATORY CYCLES
• Regular
• Mid cycle pain present
• Cervical mucus changes present
• PMS symptoms present prior to
menses
ANOVULATORY CYCLES
• Irregular
• No mid cycle pain
• Cervical mucus changes absent
• PMS symptoms absent

13. • Duration
• Period of physical presence with
husband
MARITAL HISTORY

14. • Frequency of intercourse
• Vaginismus
• Knowledge of fertile period and ovulation
COITAL HISTORY

16. • Previous pregnancy – Spontaneous or
after treatment for infertility
• Abortion
• Ectopic pregnancy
• Puerperal sepsis
OBSTETRIC HISTORY

18. • Height, Weight and BMI
• Thyroid enlargement, nodule or tenderness
• Breast secretion and their character
• Signs of androgen excess
• Pelvic or abdominal tenderness
• Vaginal or cervical abnormality, secretions or discharge
• Mass, tenderness or nodularity in the adnexa or cul-de-sac
PHYSICAL EXAMINATION

19. Infertility one year or
longer
Initial evaluation, history,
physical exam
Irregular menses
No ovul. by tests
HSG -
Tubal block
Anovulatory Tubal factors
Normal tests
Unexplained
infertility
HSG -
Anomaly of cavity
Uterine factor
Abnormal semen
analysis
Male factor
Counselling and Psychosocial support
If multiple factors present, investigate and manage concurrently

20. ANOVULATION
Normal or high day 3 FSH
and LH
Ovarian disorders
Low FSH, LH and E2 Abnormal TSH or T4 High sProlactin levels
Low LH, FSH, TSH, GH,
ACTH
Hypothalamic Disorders Thyroid disease Hyperprolactinemia Panhypopituitarism
Anorexia Hypothyroidism MRI Brain Assess and treat condition
Hypogonadotropic
Hypogonadism
Hyperthyroidism Pituitary microadenoma
Other abnormal brain
masses
Ovulation induction –
GnRH
Ovulation induction – FSH
I.U. / Timed intercourse
Treat underlying cause

21. OVARIAN DISEASES
Infrequent menses
Dec. estrogenization
High FSH, LH
Day 3 FSH
AMH
Advanced age
S&S of:
Hyperandrogenism
Oligomenorrhoea/ano
vulation
Premature ovarian
failure
Decreased ovarian
reserve
PCOD
Usually irreversible
Increased age –
decreased egg quality
Low chances of
treatment success
Increased risk of
aneuploidy
Ovulation induction
ART
IVF – Donor egg
Discuss adoption
IVF or I.U.I
Medical management
Surgical Management

22. RULE OF 4
• 4 punctures to be made on each
ovary
• 4 millimetre in diameter
• 40 watt current
• 4 seconds

23. OVULATION INDUCTION
• Infertility due to anovulation
• Necessary to exclude important pathologies before induction
and to identify successful form of treatment
• INITIAL EVALUVATION:
• IGT (35%)
• Semen analysis (20-40%)
• HSG / TVS

24. CLOMIPHENE CITRATE
• Non-Steroidal triphenyl ethylene derivative
• Acts as a SERM
• Both estrogen agonist and antagonist action
• Two stereoisomers : ENCLOMIPHENE and
ZUCLOMIPHENE
• MOA: Compete with the endogenous estrogen for the nuclear
receptors –> Inhibits the feedback on the hypothalamus –>
Increases GnRH pulse –> Increased ovulation

25. INDICATIONS
• DOC for ovulation induction in ANOVULATORY
INFERTILE WOMEN
• INEFFECTIVE in Women with Hypogonadotropic
hypogonadism
• Effective in Short Luteal Phase
• Empiric clomiphene treatment is most effective with I.U.I.

26. TREATMENT REGIMEN
• Started on 2nd to 5th day after onset of spontaneous or
progestin-induced menses
• 50mg tablet daily for 5-day interval – 52% success (FDA
approved)
• Max dose – 150mg daily
• Lower dose (12.5 – 25mg) – highly sensitive women

28. MONITORING OF CLOMIPHENE ACTIVITY
• Serial Transvaginal Ultrasound
• Serum progesterone concentration
• Midcycle urinary LH surge

29. SIDE EFFECTS
• Palinopsia, Scotoma
• Transient hot flashes
• Mood swings
• Headache
• Breast tenderness
• Nausea

30. RISKS
• Multiple pregnancy (7-10%)
• No risk of birth defects
• Ovarian hyperstimulation syndrome (OHSS)

31. COMBINATION TREATMENTS
• Clomiphene and Glucocorticoids
• Clomiphene and hCG
• Clomiphene and Metformin
• Clomiphene with hMG

32. GONADOTROPINS
• Used in CLOMIPHENE RESISTANT cases
• hMG ( Human menopausal gonadotropin ) – contains both FSH and LH
• Recombinant FSH – only FSH activity
• Dose : 50 – 75 mIU/ml of FSH, given I.M. on day 5 of cycle
• TVS monitoring
• STEP UP REGIMEN is followed

33. AROMATASE INHIBITORS
• Inhibits enzyme AROMATASE, the enzyme which catalyzes the rate-
limiting step in estrogen production.
• Commonly used : ANASTRAZOLE and LETROZOLE
• MOA : Inhibits the peripheral conversion of testosterone to estrogen
causing a fall in the estrogen levels --> Increase in FSH levels -->
Ovulation --> Increased production of estrogen by follicle --> Negative
feedback --> Growth of dominant follicle
• NOT FDA APPROVED

34. TREATMENT REGIMEN
• Letrozole (2.5 – 7.5 mg daily) and Anastrazole (1mg) – 5 day interval
• Higher pregnancy rates when compared to clomiphene citrate (17.4% vs
12.4%)

35. RESULTS OF TREATMENT WITH AROMATASE
INHIBITOR
• EFFECTIVE IN CLOMIPHENE RESISTANT CASES
• Trials show that 75% anovulatory clomiphene-resistant women and 50%
women with PCOS ovulated following letrozole.

36. GnRH ANTAGONIST
• PULSATILE GnRH – TOC for HYPOGONADOTROPIC
HYPOGONADISM
• MOA: Blocks the GnRH receptors in pituitary gland
• PREVENTS PREMATURE LH SURGE and thus premature endogenous
ovulation in patients undergoing exogenous stimulation with FSH in preparation
for IVF.
• I.M. or S.C.
• Available preparations : CETRORELIX, GANIRELIX
• Risk of hyperstimulation is less compared to hMG

37. TUBAL FACTORS
TUBAL OCCLUSION
PROXIMAL OCCLUSION DISTAL OCCLUSION
• Microsurgical
segmental tubal
resection &
anastomosis
• Proximal tubal
cannulation using
hysteroscopy or
fluoroscopy
Fimbriolysis
Fimbrioplasty
Neosalpingostomy
BIPOLAR OCCLUSION
IVF

38. UTERINE FACTORS
Pelvic
Tuberculosis
Polyps
Cat I –
HRZE(2)/HR(4)
Polypectomy
Uterine
Hypoplasia
Surrogacy
Fibroids
GnRH
Myomectomy
Ashermann’s
syndrome
Adhesiolysis
IUCD with OCP

39. CERVICAL FACTORS
CERVICITIS
POOR CERVICAL
MUCUS
ANTI-SPERM Ab
TREAT THE CAUSE IUI
IMMUNO-
SUPRESSANTS

40. VAGINISMUS & DYSPAREUNIA
VAGINISMUS:
• Essential to win the confidence of the couple
• Counselling
• Fenton operation ( for rigid hymen )
• Plastic dilator insertion
DYSPAREUNIA:
• Lubricants (K.Y. Jelly)
• Lignocaine for pain
• Treat local cause

41. ENDOMETRIOSIS
SYMPTOMATIC ASYMPTOMATIC
Observe 6-8
months
Investigate
GnRH analogues
Letrozole
RU-486
Destruction by
cautery
Excision of cyst
Drainage of
chocolate cyst
Salpingo-
oophorectomy

42. • Clinical Gynecologic Endocrinology and Infertility – Speroff 8E
• Berek & Novak’s Gynecology 15E
• Undergraduates Manual for Clinical Cases in Obstetrics and
Gynaecology
• Shaw’s Textbook of Gynaecology 15E
• NICE Guidelines – Fertility problems: assessment and treatment
• Kaplan & Sadock’s Synopsis of Psychiatry – 11E
REFERENCES

43. If it seems slow in coming,
wait patiently,
For it will surely take place.
It will not
be denied.